Inspection on 22/11/05 for White Cliffs Lodge

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

White Cliffs Lodge 17/01/10

White Cliffs Lodge 27/06/08

White Cliffs Lodge 05/12/07

White Cliffs Lodge 05/02/07

White Cliffs Lodge 14/06/06

White Cliffs Lodge 15/06/05

White Cliffs Lodge 12/01/05

White Cliffs Lodge 25/11/04

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Thorndene

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Primrose Lodge and Primrose Court Primrose Lodge Primrose Road Dover Kent CT17 0EX Lead Inspector Mrs Michele Etherton Announced Inspection 22nd November 2005 09:45 Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Primrose Lodge and Primrose Court Address Primrose Lodge Primrose Road Dover Kent CT17 0EX 01304 219213 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Beacon Care Holdings PLC Miss Amy Price Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom eight is the specified room for one Service User with LD/PD. Date of last inspection 15th June 2005 Brief Description of the Service: Primrose Lodge and Primrose Court are one registered service, comprised of 2 adjacent buildings. These are situated in a residential and industrial area of Dover. They are close to the town centre and local facilities, and near to the sea. Primrose Lodge is a purpose built Home for up to 8 learning disabled Service Users. All bedrooms are for single occupancy, and there are 6 on the ground floor, and 2 on the lower ground floor. The lower ground floor has doors opening out on to the rear garden. One of the bedrooms on this floor has been altered to accommodate a wheelchair user, and has a disabled shower and toilet facility opposite to it on the same corridor. Primrose Lodge provides 3 communal rooms for both buildings, and also includes staff and laundry facilities. Primrose Court is a purpose built unit of 6 flats: two 1-bedroom flats, and four 2-bedroom flats, and therefore providing accommodation for up to 10 Service Users. These have been designed for use by more able Service Users who require minimal support. Each flat has its own kitchen/lounge/diner, separate bedrooms, a bathroom with toilet, and a separate toilet. Service Users have access to the communal and laundry facilities at Primrose Lodge. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and took place over a period of 7 hours. The inspection was carried out as part of the normal inspection programme and aimed to assess progress made by the home since the last inspection on addressing an outstanding requirement and a number of good practice recommendations. In addition remaining key standards were assessed on this occasion. The inspector made a full tour of both buildings and inspected a number of records. All service users were seen at inspection and two spoken with in some depth. The three staff on duty including the manager were also spoken with during the course of the visit. Unfortunately no relatives were available to speak with, although inspection comment cards received from them have contributed to the development of this report. What the service does well: What has improved since the last inspection? What they could do better: Although staff feel communication has improved within the staff team, they are concerned that their views and observations in respect of service users do not sufficiently influence the development of care plans, risk assessments and behaviour management guidelines utilised within the home and with which they have to work. The providers have not addressed satisfactorily previous inspection recommendations in regard to risk assessments and behaviour guidelines and this inspection has again highlighted serious shortfalls in these Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 6 areas for some users; as a consequence two new requirements have been issued in respect of these matters. The inspection highlighted some shortfalls in recording in respect of care plans, complaints information and accident reporting that may compromise user safety and rights if not addressed. Although the providers are trying to move the service forward and address outstanding requirements and recommendations, this is undertaken in isolation with little reference to the views of staff, users and other stakeholders, a system for self auditing by the service and the introduction of quality assurance measures that incorporate the views of users and other stakeholders needs to be introduced, in addition the home will need to evidence how these views influence the development of the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Progress has been made to ensure new service users needs are assessed and can be met by the home, however, the absence of appropriate support and guidelines for staff in managing behaviours that arise post admission may undermine their ability to meet needs effectively in the longer term. The home has made limited progress in ensuring all service users receive a copy of their contract. EVIDENCE: The inspector noted that one new service user had been admitted to the home since the last inspection, the inspector was satisfied that an assessment of needs had been undertaken; in discussion with staff and the service user concerned the inspector was satisfied that the home can meet their needs at this time, but there is a recognition that staff will need additional training to effectively support aspects of the individuals mental health needs and this is a recommendation (see standard 32). The home is currently building user numbers and the current user group vary greatly in their abilities, the inspector found some difficulty in understanding who the service was being provided for as clearly one of the service users is far less able and more dependent, the other service users all having the potential to move on to more independence. Clearly there is a need to attain a balance within the household not only in respect of gender but abilities to ensure the needs of more vulnerable users do not become marginalised. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 9 The inspector expressed concern that where difficulties arise post admission with regard to behaviour management, a failure to recognise shortfalls in the management of such behaviour by staff and the development of appropriate guidelines for them to follow is likely to compromise the ability of the home to work effectively with those users in the long term, and in the short term could place both users and staff at risk (see St.23). The home has attempted to obtain signed contracts from service user representatives where users lack capacity to do so themselves, but is having little success to date, with most funding authorities preferring to issue their own local authority contract to service providers. Whilst this is usual practice there is still a need for service users and their relatives to be informed about the services to be provided to them, the cost of their stay and how it is to be funded and the conditions of living in the home and their rights. The inspector has suggested the home develops a terms and conditions document for those users who are publicly funded that contains all the elements highlighted within the standard and which service users or their representatives can endorse, this remains an outstanding recommendation to be achieved Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9,10 Care plans and risk assessments are in place but without improved detail there is no assurance that care needs will be met consistently and appropriately, or that risks have been fully assessed. Progress has been made to ensure service user records and information are handled appropriately and kept securely. EVIDENCE: Care plans were viewed for all four service user’. Discussion with staff indicated that care plans have been developed, assessment of these however, by the inspector indicated some glaring omissions which could compromise the quality of care and support offered to service users, examples of these omissions were an absence of information regarding leg splints needed for one service user, a lack of detail in respect of how a service users mental health issues impact on them, and what treatment they receive to support and maintain good mental health, another care plan for a service user who experiences seizures did not give clear information as to how these affected the individual, the monitoring arrangements in place for logging seizures and how staff were to manage them. Care plans should also make reference to the specific personal hygiene routines that may be required for those users from different ethnic backgrounds who may require additional support around skin Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 11 and hair care routines. The home’s care plans are still unsigned by users or their representatives although reviews are planned, it was suggested that the home needs to actively seek endorsement of care plans, and these are recommendations. A range of environmental and individual risk assessments were viewed at inspection and there was evidence of recent updating, however, the inspector expressed concerns that content of risk assessments could be improved to ensure actions taken to minimise risk were fully addressed e.g. staff driving licences are checked annually to ensure all staff drivers are competent to do so. Evidence of monitoring of users in using roads independently etc supports judgements made in respect of risk. In addition the inspector expressed concern that two service users who at times exhibit verbal or physical aggression are assessed as able to access the community independently, without appropriate safeguards built into the risk assessment process e.g. risk assessment of these individuals every time they leave the premises to assess mood etc, whether they pose a risk to others in the community, particularly where they may experience confrontation and their likely response to it. In view of these concerns the inspector does not feel that a previous recommendation has been addressed, and would require that risk assessments are reviewed to address shortfalls in actions taken to minimise risk identified and that individual user risk assessments are developed with reference to behaviour management guidelines. Service users accessing the community independently who have behaviour difficulties involving aggression to others should be risk assessed each time they access the community with and without staff support, and this should be recorded. Actions taken to minimise risk should also be noted in risk assessment documentation relating to individuals. The service user concerned or their representatives should endorse written ‘Risk’ assessments’. The inspector reviewed the security of files and documentation and was satisfied that an outstanding requirement to ensure service users records are kept in a secure environment to protect their confidentiality has been addressed. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, Feedback from users indicated that there are opportunities for personal development; a lack of effective guidelines linked to identified goals could inhibit continuity and progress of measurable and lasting improvements in communication, emotional development and independent living skills. EVIDENCE: During the inspection four service users were met, but only two were spoken with in depth. One service user spoken with indicated that they go to church regularly on a Sunday. Both service users indicated a wish to become more independent and saw themselves as moving on from the main house into the flats next door, service users confirmed that they undertake some independent living activities e.g. tidying their bedrooms, helping with cooking, preparing food and cooking, one of those spoken with travels independently outside of the home in the local area. Each user has an activity programme, but there appeared to be no guidelines in place for staff to follow to support development of individual users, provide continuity and achieve identified goals. The inspector does not consider this outstanding recommendation to have been addressed. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 13 Discussion with one service user highlighted a need for advocacy support to enable them to exercise more control over their life, routines and daily activities, and to withstand pressures from relatives in these areas, the home has already made a referral on their behalf to a local advocacy group. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Service users and staff would benefit from the development of a cross gender care policy and a more balanced team in respect of male/female staff. Service users are enabled and supported to access routine healthcare appointments, but would benefit from improved recording in respect of the effectiveness of medical treatments received. Progress has been made to improve the storage of medication but service users would benefit from improvements to recording of medication. EVIDENCE: Currently there is a predominance of female staff to support a male dominated user group, this affords little opportunity for male users to exercise choice and preference in respect of who supports them with their personal hygiene, and leaves little opportunity for the development of male role models. One male service user indicated a preference for a male carer; another has displayed sexualised behaviour to a female staff member and would also benefit from having a male carer for personal hygiene routines. Discussion with staff indicated that previously two male carers have been rostered on together with no female carer to support the only female service user, this is unacceptable and should not happen in future even if additional male staff’ are employed. It is a recommendation that the home develop a cross gender care policy, which takes account of emergency situations where staff of the same gender may not immediately be available. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 15 The inspector viewed a daily file for one user that clearly indicated routine and specialised health care appointments are happening. The home has addressed a previous omission in recording regarding seizures recorded on charts also being recorded in daily logs, recommended improvements to care plan information detailing how seizures are to be managed by staff should ensure support offered to service users affected is consistent. The home has addressed a previous recommendation to improve the storage of medication in Primrose Lodge. A medication round was observed on this occasion and MAR sheets viewed. It was noted that medication received by the home had not been recorded on this occasion, previous MAR sheet records viewed provided evidence that this is routinely undertaken and appears to have been an oversight this time, the home manager was reminded of the need to undertake routine auditing of MAR sheets to ensure they are being completed correctly and this is a recommendation. Signatures of those able to administer were available to view except for regular agency staff currently being used, these signatures need to be added and this is a recommendation. Medication profiles are in place, and it is recommended that details of where topical medications are to be used should be clearly stated. Guidelines for the use of PRN medications and homely remedies should also be provided and these are recommendations. Liquid medications are dated upon opening and the home should develop a system for the routine auditing of liquid medications and this is a recommendation. It was further suggested that liquid medications whilst stored separately from tablets, could be placed on a tray or in a container to avoid seepage. Medication consents to administration of medication by staff must be clearly detailed within user files and endorsed by users or where they lack the capacity to do so, their representatives. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users and relatives would benefit from improved access to the complaints procedure. The health and safety of service users could be compromised by the lack of adequately detailed behaviour management guidelines EVIDENCE: Feedback from comment cards received from representatives indicated that at least 50 were unaware of the complaints procedure. A complaints procedure was on display in the home at this visit but the inspector understood this to be a very recent addition. The home caters for a range of user abilities and will need to give consideration as to how the complaints procedure can be made more accessible to those users unable to read. A complaints log was viewed at inspection, whilst this indicated that investigations had taken place and complaints subsequently resolved, there was insufficient detail to determine if this had been addressed robustly, nor referencing to other documentation that may have supported this. It is a recommendation that service users and their relatives/representatives are made aware of the complaints procedure, that an accessible version is considered for service users, that details of complaints investigations and actions taken are clearly recorded and evidenced. Whilst the home has made some initial progress in developing behaviour guidelines in response to a previous recommendation, the inspector found these to be inadequately detailed for staff’ to follow, and consequently are open to interpretation. The inspector expressed concern in respect of how staff’ are managing one service users behaviour where this had on several occasions become extremely violent; discussions with staff indicated little knowledge as to how they could Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 17 appropriately manage this individuals behaviour, and staff were genuinely concerned at this. The inspector expressed the view that the lack of detailed behaviour management strategies/guidance for staff to work to, left service users at risk of receiving inconsistent and inappropriate responses from staff, and could compromise the safety of all concerned. It is a requirement therefore, that detailed behaviour management strategies/guidelines are developed, as a matter of priority and these should be endorsed by users or their representatives the effectiveness of these strategies should be monitored and reviewed on a regular basis. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Service users benefit from living in a clean, comfortable environment that is adapted to meet their needs, progress is being made by the home on making the environment more homely. EVIDENCE: The inspector toured both Primrose Lodge and court. The court is currently empty, but was clean and comfortably furnished with good quality fabrics and furnishings. The inspector viewed all the empty bedrooms at the lodge and two of those currently occupied. Bedrooms viewed had been personalised to reflect individual tastes and interests, as had the communal lounge on the lower ground floor. The main lounge and other communal areas and bathrooms are still in need of some homely touches and the manager is taking steps to address this. A previous recommendation that the home adjust the shower on the lower ground floor to make it easier to turn on and off has been addressed, staff and a service user confirmed that the replacement unit is easier to use, although the inspector still found this somewhat stiff, and should be monitored for ease of use. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 19 The inspector reminded the home manager of the need to ensure that wheelchairs kept in the home are regularly serviced and this is a recommendation Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34,35, 36 Shortfalls in specialised training courses must be addressed to ensure staff can appropriately meet service user needs. Service users benefit from a good staff to user ratio, however, Staffing levels should be reviewed to ensure behaviour management strategies can be effectively and safely maintained. The home has made progress to ensure staff files contain required documentation. Service users needs may not be met appropriately through shortfalls in the current staff induction process. Staff are supported through individual supervision, with their manager. EVIDENCE: From a review of user files and discussion with staff, they are still to receive training in specialist areas of need e.g. epilepsy, autism, mental health experienced by service users currently residing in the home, these have been identified as training needs for the staff team and it is a recommendation that the home progress access to this training for staff. Staff and users spoken with felt that staffing levels were currently adequate, the home manager is aware that some relatives may notice a substantial drop in visible staffing numbers, but this is reflective of the current numbers and dependency of users in the Lodge. The home currently uses 1 or 2 regular agency staff to cover for sickness and a vacant post, by using the same staff they are hoping to maintain continuity for service users. A recruitment drive is currently underway. Whilst staffing levels appear adequate at the present time, this presumes that staff are not required to undertake any restraint of Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 21 those service users exhibiting challenging behaviour, should this feature in any behaviour management strategy for a service user staffing levels would have to be reviewed immediately to reflect this change. As discussed previously in the report the current staff mix does not reflect the gender composition of the user group, and consideration will need to be given to trying to attain a more balanced and representative group, both in culture/ gender and age. Staff spoken with confirmed that regular staff meetings take place and they are able to see minutes of these and submit issues for discussion if they are unable to attend. The inspector viewed 3 staff files and was satisfied that the required level of documentation was in place. The inspector suggested that the home might wish to improve the robustness of its recruitment of staff by more thoroughly exploring employment history of prospective staff, even where two recent employers can be approached for references. The inspector viewed induction information for a current member of staff and was concerned that this appears to not have been undertaken thoroughly, with much of the induction signed off in one day, the current manager was aware of the need for induction of new staff to be undertaken over a period of 12 weeks in line with the recent changes to induction standards, it is a recommendation that new staff induction is undertaken in keeping with the new induction standards and to specified timescales. Discussion with staff members confirmed that they receive regular formal supervision from their manager and records of some staff supervisions were noted at inspection, the content being in keeping with that expected within the standard. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 The home needs to implement a system of self-auditing and quality assurance that engages with all stakeholders and can evidence how this influences change and development in the service. Shortfalls in staff recording of accidents could compromise the safety of users. EVIDENCE: The inspector was advised that the company would be introducing an audit system for the home to implement; this is currently awaiting final checks before introduction. Currently the home already undertakes a staff survey and analysis of this feedback has been completed, however, the home were unable to evidence how this feedback influences change and development of the service. The home recognise the need to engage with service users, their families, and professionals involved with the service users to gain a broader view of the current service. User views should be incorporated into service user guide information, and a report detailing analysis of service user views should be published and a copy made available to CSCI. The home is still to draft a service development plan. The inspector was satisfied that the home is aware of these shortfalls and is taking steps to address them; it is therefore a Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 23 recommendation that the home progress the development of its quality assurance/quality monitoring systems. The inspector viewed the accident book, during the inspection visit; eight new accidents were recorded since the last inspection, three of these occurring in incidents outside of the home. The inspector expressed concern that staff were using the accident-reporting book incorrectly and as a consequence a number of gaps appear between recorded accidents. In one case the date ands time of the accident was not recorded. The inspector discussed these shortfalls with the manager and the possibilities of incorrect or inadequate recording compromising the safety of users, it was recommended that the manager reminds all care staff of the importance of accurate recording within the accident book and reminds them of the correct way this is to be done. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 2 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 x 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Primrose Lodge and Primrose Court Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000058791.V256835.R01.S.doc Version 5.0 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(6) Requirement Timescale for action 31/12/05 2 YA23 13(6) Risk assessments are to be reviewed to address shortfalls in actions taken to minimise risk identified, user risk assessments to be developed with reference to behaviour management guidelines. Users accessing the community independently or with support who exhibit aggressive behaviour should be risk assessed each time they access the community with and without support and this should be recorded, this action should also be noted in risk assessment documentation relating to individuals. Detailed behaviour management 01/02/06 guidelines are to be developed for staff to ensure they manage behaviour in a consistent and appropriate manner that has been endorsed by all parties. The effectiveness of the strategies/guidelines should be monitored and reviewed on a regular basis. Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations To ensure that each local authority funded service user has a copy of a terms and conditions document signed by them or their representative, and that privately funded users are issued with copies of their signed contracts. Care plans would benefit from improved detail in respect of care needs, and should signed by users or their representatives. To ensure that service users have clear guidelines in place to enable staff to support them in developing independent living skills, modifying unacceptable behaviour, provide continuity of support and progression towards goals. Home to develop a cross gender care policy, which includes guidelines for staff to follow in the event of emergency situations. Home to implement a system to demonstrate the ongoing response when medical treatment is given The home manager to undertake routine auditing of MAR sheets to ensure they are being completed correctly. Signatures of regular agency staff administering medication need to be added. Details of where topical medications are to be used should be clearly stated in user files. Guidelines for the use of PRN medications and homely remedies should also be provided. The home should develop a system for the routine auditing of liquid medications. Consents to medication must be in place. Service users and their relatives/representatives are made aware of the complaints procedure, that an accessible version is considered for service users, that details of complaints investigations and actions taken are clearly recorded and evidenced. Wheelchairs kept in the home are to be regularly serviced Training in specialist areas of need e.g. Epilepsy, autism, mental health, experienced by service users currently DS0000058791.V256835.R01.S.doc Version 5.0 Page 27 2 3 YA6 YA11 4 5 6 YA18 YA19 YA20 7 YA22 8 9 YA29 YA32 Primrose Lodge and Primrose Court residing in the home, are identified as training needs for the staff team and the home should progress access to this training for staff. 10 YA35 New staff induction is to be undertaken in keeping with the new induction standards and to the specified timescales. Home to progress development of quality assurance/quality monitoring systems which engage with all stakeholders and can evidence how their views influence service development, home to publish analysis of user views annually, and draft service development plan The manager to remind all care staff of the importance of accurate recording within the accident book and refresh their understanding of the correct way this is to be done. 11 YA39 12 YA42 Primrose Lodge and Primrose Court DS0000058791.V256835.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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